The authors looked at 3701 patients under 19 years old evaluated for a cervical spine injury. Of the 44 patients with clinically significant cervical spine injury (CSI), 32 had plain films, none of which missed an injury.

32 out of 3701… or 0.86%

-There were ZERO patients under two years old with a CSI

Here is the caveat- one injury begets another. Of the 32 patients with CSI, ten (31%) had multiple lesions, with plain films not identifying all lesions in 4 patients. Given that, I think its fair to say CT (or admission for MRI) is warranted once an abnormality is found.

In summary, relevant cervical injuries in kids are rare (<1%), and plain films are a reasonable screening tool. CT is once again rarely needed, but beware since one injury seemingly begets another. I pretty much agree with the authors on this one,

“Our calculated 100 % sensitivity (90% on PECARN, finding 168 of 186 CSI) does come with a large confidence interval and it should be expected that plain film’s sensitivity for CSI is likely lower in clinical practice. However, the small risk of missed injuries from plain films must be balanced against the increased risk of malignant trans- formation from performing CT scans on all children with suspected CSI. “

Some of us have quirky things we like to do that not everyone else does– dexamethasone for sore throats, ketamine for the agitated patient (or anything really), et cetera… This paper looks at one of those things – Magnesium in asthmatics.

This was a prospective, randomized open-label study of patients between 6 and 18 years of age over a two year period who presented to an ED in Asuncion, Paraguay and were admitted for a severe asthma exacerbation.Patients were excluded if given antibiotics before or during the ED visit, febrile, or if there was suspicion for infectious etiology.All patients enrolled had no relief despite 2 hours of treatment which included dexamethasone 0.2mg/kg IV, nebulized salbutamol every 20 minutes up to 5mg and nebulized albuterol every 2 hours.There were two treatment arms, each with 19 patients: one received a 50mg/kg bolus of MgSO4, while the other group received 50mg/kg/hr/4 hrs (ie, up to 2g / hr for 4 hours – up to 8g total).Physicians in charge of patient disposition, after the initial 8 hours, were not part of the study group and blinded to the treatment received.Primary outcome was discharge at 24 hours, with secondary outcomes total LOS and cost implications.The two groups were similar in terms of age, sex, initial Wood-Downes asthma score, and peak flows.

Despite the numerous downfalls to this study (single center, open-label, prospective, small sample size…), the results are intriguing- bolus magnesium had an average LOS of 48 hours vs 34 hours for high dose prolonged infusions, had a higher cost ($834 vs $603), and fewer patients with a LOS <24 hrs (10.5% vs 47.4%).It took almost two years to get under 40 patients in this single-center study,but still, there were no adverse events and no bounceback visits within a week from discharge.Interestingly, there were no obese patients in the study – so how applicable this study is to the US patient population, I do not know (plus, salbutamol is not widely used for acute asthma in the US). That, and even for this mag-o-phile 8g per hour for 4 hours seems like alot!

Should this change your practice?Not quite yet – unless you’re not giving magnesium.In the meantime, I’ll add another one to the list of trials I’d love to see.

We can add two more pieces of literature to suggest that removable splinting alone is sufficient for the management of distal forearm torus fractures. This piece looked at 142 pediatric patients randomized to short arm cast or removable wrist splint for 3 weeks without a significant difference in pain, compliance, or complications.

Then there is this article that looked at 119 consecutive pediatric torus fractures over a one year period seen by an APRN who were immobilized with a soft cast. There were no adverse events, and no subsequent visit to fracture clinic. In comparison to previous standards of fracture clinic referral, there was a cost savings of $18596 euro (20k USD) in total.

The AAOS says, “The use of removable splints is an option when treating minimally displaced distal radius fractures.” Since this 2009 recommendation, there are now 5 publications (the two articles above, plus three from this previous post suggesting nondisplaced pediatric Torus fractures can be safely treated with a removable splint at a significant cost savings to all involved.

At what point do you consider discharging a patient after an LP? Less than 5 WBCs in CSF? Less than 10? Less than 20? What if, after you have empirically given them dexamethasone, ceftriaxone, and compazine, they feel well and have only 8 WBCs? Perhaps you’re using the bacterial meningitis score?

Well, a single-center study recently looked at outcomes for CSF culture positive bacterial meningitis for pediatric patients, aged 1 month to 18 years. 35% of these patients were under 3 months young, another 26% were 4-11 months, while only 7% were 7-10 years young, and another 4.6% 11-18 years young, so the data was quite skewed towards a younger population, which probably reflects our higher frequency of doing LPs in these age groups. They excluded traumatic taps.

Bad outcomes were defined as physical or psychological morbidities lasting longer than 6 months after the meningitis episode, including mental retardation, cerebral palsy, ataxia, hearing impairment, and epilepsy. Lost to follow up was defined as an inability to reach the patient at 6 months after the meningitis episode. Sequelae were defined as physical or psychological morbidities lasting longer than 6 months after the meningitis episode, including mental retardation, cerebral palsy, ataxia, hearing impairment, and epilepsy. Lost to follow up was defined as an inability to reach the patient at 6 months after the meningitis episode.

The results?

The numbers are small, but the message concerning: patients with >5000 WBCs had essentially the same prognosis as those with <5 WBCs. There have been case reports of this in adults, generally with poor outcomes. Going forward, if patients have any WBCs, consider placing patients in observation for monitoring and consideration of repeat LP.

If you said $400 or more, you win, and if you ordered it without PO challenging your patient, your patient just lost. Now for children, ask a parent what they would rather prefer – having their terrified & vomiting child stuck few times & made miserable – all for over $400! – or an attempt at giving the same medication orally to watch and see how the child does?

Put it that way, and parents now see the light. Bottom line is that they do not want to see their child suffer any more than we want to hear them yell down the hall after getting stuck 4 times. And besides, how much of that liter of Normal Saline that you ordered gets placed intravascularly?

A separate Cochrane Review found 1 in 33 patients given oral Zofran developed a paralytic ileus, but this was no different than the recommended low osmolarity solutions recommended by the World Health Organization. For every 25 children treated with PO Zofran, one would fail and require an IV.

Its part of the Choosing Wisely Campaign. I’ve had conversations with parents about IV or PO zofran, and most prefer not have their child tortured. They leave the ED sooner and happier, without compromising safety. Document a repeat abdominal exam, give good belly precautions to family, and you have saved everyone a good bit of time and hassle.

If you have ever said to a patient – and meant it – that they needed to stay for “antibiotics in the IV” and you were not giving CefeVancoSyn, read further and take your educational beating. There is a paucity of data on IV being equivalent to PO, but at least there is some – and its reviewed in this post. However, there is no significant data on an IV antibiotic being better, faster, stronger than its PO counterpart – for just about anything clinically significant, except for very antibiotic-specific instances (example: IV vs PO vanco, for SSTI or CDiff).

In a comparison of PO Augmentin vs IV Augmentin transitioned to PO Augmentin vs IV Cephalosporin transitioned to PO Cephalosporins for lower respiratory tract infections, there were no significant differences between clinical outcome or mortality. Patients in the PO only group, shockingly, had a reduced hospital stay.

In a Cochrane Review, oral treatment has been show to be an acceptable alternative to IV antibiotic treatment in febrile neutropenic patients without pneumonia or skin / soft tissue infection, organ failure, or central line infection, who are also hemodynamically stable. Mortality and treatment failure were similar. I am not saying to discharge them on oral antibiotics from the ED – despite MASCC saying you can – but you may transition them home sooner and stop the snowball effect “the need for IV antibiotics” can have on a patient.

There are a handful of studies which show PO antibiotics equivalent to IV antibiotics for initial management of pediatric pyelonephritis – with comparable renal scarring, adverse reactions, and treatment failure as well.

Next time you start IV Levaquin for “a loading dose” on a patient that can tolerate oral antibiotics, think about this post, the added cost to the patient, and nursing time spent setting up IV treatment. Stop the snowball effect in the ED, the patient can continue PO on the floor, and likely leave the hospital sooner, without compromising safety.